103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB2088

 

Introduced 2/9/2023, by Sen. Celina Villanueva

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-30.1
305 ILCS 5/5A-12.7

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires managed care organizations (MCOs) to pay a clean claim (rather than claim) within 30 days of receiving a claim. Defines "clean claim" as a claim that contains all the essential information needed to adjudicate the claim or a claim for which a managed care organization does not request within 30 days of receipt any additional information to adjudicate the claim. Contains provisions concerning MCO reports to providers on the receipt and payment of claims; MCO data collection requirements; providers' right to file suit to recover outstanding payments; quarterly audits of each MCO's requests for provider information to adjudicate claims; MCO claims processing and performance analysis; quarterly audits of MCOs payments to hospitals; the segregation of State-issued Medicaid funds received by MCOs for payments to providers; and other matters. Amends the Hospital Provider Funding Article of the Code. Requires the Department of Healthcare and Family Services to calculate, at least quarterly, all Hospital Assessment Program-related funds paid to each hospital, whether paid by the Department or an MCO, including the amounts integrated into rate increases and distributed as provided under the Code.


LRB103 28984 KTG 55370 b

 

 

A BILL FOR

 

SB2088LRB103 28984 KTG 55370 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-30.1 and 5A-12.7 as follows:
 
6    (305 ILCS 5/5-30.1)
7    Sec. 5-30.1. Managed care protections.
8    (a) As used in this Section:
9    "Clean claim" means: (i) a claim that contains all the
10essential information needed to adjudicate the claim or (ii) a
11claim for which a managed care organization does not request
12within 30 days of receipt any additional information to
13adjudicate the claim. A resubmitted claim shall be considered
14a clean claim on the resubmission date if it meets the
15foregoing criteria.
16    "Managed care organization" or "MCO" means any entity
17which contracts with the Department to provide services where
18payment for medical services is made on a capitated basis.
19    "Emergency services" include:
20        (1) emergency services, as defined by Section 10 of
21    the Managed Care Reform and Patient Rights Act;
22        (2) emergency medical screening examinations, as
23    defined by Section 10 of the Managed Care Reform and

 

 

SB2088- 2 -LRB103 28984 KTG 55370 b

1    Patient Rights Act;
2        (3) post-stabilization medical services, as defined by
3    Section 10 of the Managed Care Reform and Patient Rights
4    Act; and
5        (4) emergency medical conditions, as defined by
6    Section 10 of the Managed Care Reform and Patient Rights
7    Act.
8    (b) As provided by Section 5-16.12, managed care
9organizations are subject to the provisions of the Managed
10Care Reform and Patient Rights Act.
11    (c) An MCO shall pay any provider of emergency services
12that does not have in effect a contract with the contracted
13Medicaid MCO. The default rate of reimbursement shall be the
14rate paid under Illinois Medicaid fee-for-service program
15methodology, including all policy adjusters, including but not
16limited to Medicaid High Volume Adjustments, Medicaid
17Percentage Adjustments, Outpatient High Volume Adjustments,
18and all outlier add-on adjustments to the extent such
19adjustments are incorporated in the development of the
20applicable MCO capitated rates.
21    (d) An MCO shall pay for all post-stabilization services
22as a covered service in any of the following situations:
23        (1) the MCO authorized such services;
24        (2) such services were administered to maintain the
25    enrollee's stabilized condition within one hour after a
26    request to the MCO for authorization of further

 

 

SB2088- 3 -LRB103 28984 KTG 55370 b

1    post-stabilization services;
2        (3) the MCO did not respond to a request to authorize
3    such services within one hour;
4        (4) the MCO could not be contacted; or
5        (5) the MCO and the treating provider, if the treating
6    provider is a non-affiliated provider, could not reach an
7    agreement concerning the enrollee's care and an affiliated
8    provider was unavailable for a consultation, in which case
9    the MCO must pay for such services rendered by the
10    treating non-affiliated provider until an affiliated
11    provider was reached and either concurred with the
12    treating non-affiliated provider's plan of care or assumed
13    responsibility for the enrollee's care. Such payment shall
14    be made at the default rate of reimbursement paid under
15    Illinois Medicaid fee-for-service program methodology,
16    including all policy adjusters, including but not limited
17    to Medicaid High Volume Adjustments, Medicaid Percentage
18    Adjustments, Outpatient High Volume Adjustments and all
19    outlier add-on adjustments to the extent that such
20    adjustments are incorporated in the development of the
21    applicable MCO capitated rates.
22    (e) The following requirements apply to MCOs in
23determining payment for all emergency services:
24        (1) MCOs shall not impose any requirements for prior
25    approval of emergency services.
26        (2) The MCO shall cover emergency services provided to

 

 

SB2088- 4 -LRB103 28984 KTG 55370 b

1    enrollees who are temporarily away from their residence
2    and outside the contracting area to the extent that the
3    enrollees would be entitled to the emergency services if
4    they still were within the contracting area.
5        (3) The MCO shall have no obligation to cover medical
6    services provided on an emergency basis that are not
7    covered services under the contract.
8        (4) The MCO shall not condition coverage for emergency
9    services on the treating provider notifying the MCO of the
10    enrollee's screening and treatment within 10 days after
11    presentation for emergency services.
12        (5) The determination of the attending emergency
13    physician, or the provider actually treating the enrollee,
14    of whether an enrollee is sufficiently stabilized for
15    discharge or transfer to another facility, shall be
16    binding on the MCO. The MCO shall cover emergency services
17    for all enrollees whether the emergency services are
18    provided by an affiliated or non-affiliated provider.
19        (6) The MCO's financial responsibility for
20    post-stabilization care services it has not pre-approved
21    ends when:
22            (A) a plan physician with privileges at the
23        treating hospital assumes responsibility for the
24        enrollee's care;
25            (B) a plan physician assumes responsibility for
26        the enrollee's care through transfer;

 

 

SB2088- 5 -LRB103 28984 KTG 55370 b

1            (C) a contracting entity representative and the
2        treating physician reach an agreement concerning the
3        enrollee's care; or
4            (D) the enrollee is discharged.
5    (f) Network adequacy and transparency.
6        (1) The Department shall:
7            (A) ensure that an adequate provider network is in
8        place, taking into consideration health professional
9        shortage areas and medically underserved areas;
10            (B) publicly release an explanation of its process
11        for analyzing network adequacy;
12            (C) periodically ensure that an MCO continues to
13        have an adequate network in place;
14            (D) require MCOs, including Medicaid Managed Care
15        Entities as defined in Section 5-30.2, to meet
16        provider directory requirements under Section 5-30.3;
17            (E) require MCOs to ensure that any
18        Medicaid-certified provider under contract with an MCO
19        and previously submitted on a roster on the date of
20        service is paid for any medically necessary,
21        Medicaid-covered, and authorized service rendered to
22        any of the MCO's enrollees, regardless of inclusion on
23        the MCO's published and publicly available directory
24        of available providers; and
25            (F) require MCOs, including Medicaid Managed Care
26        Entities as defined in Section 5-30.2, to meet each of

 

 

SB2088- 6 -LRB103 28984 KTG 55370 b

1        the requirements under subsection (d-5) of Section 10
2        of the Network Adequacy and Transparency Act; with
3        necessary exceptions to the MCO's network to ensure
4        that admission and treatment with a provider or at a
5        treatment facility in accordance with the network
6        adequacy standards in paragraph (3) of subsection
7        (d-5) of Section 10 of the Network Adequacy and
8        Transparency Act is limited to providers or facilities
9        that are Medicaid certified.
10        (2) Each MCO shall confirm its receipt of information
11    submitted specific to physician or dentist additions or
12    physician or dentist deletions from the MCO's provider
13    network within 3 days after receiving all required
14    information from contracted physicians or dentists, and
15    electronic physician and dental directories must be
16    updated consistent with current rules as published by the
17    Centers for Medicare and Medicaid Services or its
18    successor agency.
19    (g) Timely payment of claims.
20        (1) The MCO shall pay a clean claim within 30 days of
21    receiving a claim that contains all the essential
22    information needed to adjudicate the claim.
23        (2) The MCO shall notify the billing party of its
24    inability to adjudicate a claim within 30 days of
25    receiving that claim.
26        (2.5) At the time of payment for a claim, MCOs shall

 

 

SB2088- 7 -LRB103 28984 KTG 55370 b

1    report to the provider (i) the date of receipt of the claim
2    by the MCO; (ii) the date of payment of the claim; and
3    (iii) whether the MCO considers the claim to have been a
4    clean claim.
5        (2.6) MCOs shall provide to safety-net hospitals on a
6    monthly basis a report of all claims paid the preceding
7    month stating (i) the dates of receipt and payment of each
8    of the claims and (ii) whether the MCO considers the claim
9    to have been a clean claim. The reports shall be provided
10    in both portable document format (PDF) and Excel
11    spreadsheet formats.
12        (2.7) MCOs shall collect and maintain the following
13    data for each claim submitted by a provider:
14            (A) the date the claim was received by the MCO;
15            (B) if applicable, the date any additional
16        information was requested by the MCO;
17            (C) if applicable, the date additional information
18        was received by the MCO;
19            (D) the date the claim was adjudicated; and
20            (E) the date the claim was denied or paid. MCOs
21        shall provide this data to any individual provider
22        that requests it, within 30 days after receiving the
23        provider's written request.
24        (3) The MCO shall pay a penalty that is at least equal
25    to the timely payment interest penalty imposed under
26    Section 368a of the Illinois Insurance Code for any claims

 

 

SB2088- 8 -LRB103 28984 KTG 55370 b

1    not timely paid.
2            (A) When an MCO is required to pay a timely payment
3        interest penalty to a provider, the MCO must calculate
4        and pay the timely payment interest penalty that is
5        due to the provider within 30 days after the payment of
6        the claim. In no event shall a provider be required to
7        request or apply for payment of any owed timely
8        payment interest penalties.
9            (B) Such payments shall be reported separately
10        from the claim payment for services rendered to the
11        MCO's enrollee and clearly identified as interest
12        payments.
13            (C) Each MCO, including any owned, operated, or
14        controlled by any governmental agency, shall pay
15        interest for untimely payment of claims in accordance
16        with this subsection.
17        (3.1) On a quarterly basis, and within 30 days after
18    the end of each calendar quarter, each MCO shall report to
19    the Department the following information on a
20    provider-by-provider basis for each provider that
21    submitted 20 or more Medicaid claims to the MCO in the
22    quarter:
23            (A) the total number of claims received from the
24        provider during the prior quarter;
25            (B) the percentage of all such claims that were
26        clean claims;

 

 

SB2088- 9 -LRB103 28984 KTG 55370 b

1            (C) the percentage of all claims the MCO paid
2        within 30 days of receiving the claim;
3            (D) the percentage of all claims the MCO paid
4        within 90 days of receiving the claim;
5            (E) the percentage of all clean claims the MCO
6        paid within 30 days of receiving the claim; and
7            (F) the percentage of all clean claims the MCO
8        paid within 90 days of receiving the claim.
9        Such information shall be provided by the Department
10    to the provider to whom the data applies within 14 days of
11    request by the provider.
12        (3.2) The provisions of this subsection, and others
13    dealing with timely payment of claims, are intended for
14    the benefit of the Department and of the providers. The
15    Department and each provider shall have the right to bring
16    suit in any court of competent jurisdiction to enforce
17    these provisions, including recovery of payments due to
18    providers, and to obtain any information related to
19    individual providers required to be provided under this
20    subsection. The court may enter any appropriate
21    compensatory, declaratory, or injunctive relief. In any
22    action or proceeding to enforce this subsection, the court
23    shall have the authority to award the prevailing party all
24    fees and costs incurred, including attorneys' fees.
25        (3.3) On a quarterly basis, the Department shall audit
26    a representative sample of each MCO's requests for

 

 

SB2088- 10 -LRB103 28984 KTG 55370 b

1    information from providers to determine whether the
2    requested information is necessary to adjudicate the
3    claim. If the Department determines that the MCO requested
4    information that was not necessary to adjudicate the
5    claim, the MCO shall be required to pay a penalty to the
6    Department and interest to the provider computed from the
7    date of the submission of the claim to the MCO.
8        (4)(A) The Department shall require MCOs to expedite
9    payments to providers identified on the Department's
10    expedited provider list, determined in accordance with 89
11    Ill. Adm. Code 140.71(b), on a schedule at least as
12    frequently as the providers are paid under the
13    Department's fee-for-service expedited provider schedule.
14        (B) Compliance with the expedited provider requirement
15    may be satisfied by an MCO through the use of a Periodic
16    Interim Payment (PIP) program that has been mutually
17    agreed to and documented between the MCO and the provider,
18    if the PIP program ensures that any expedited provider
19    receives regular and periodic payments based on prior
20    period payment experience from that MCO. Total payments
21    under the PIP program may be reconciled against future PIP
22    payments on a schedule mutually agreed to between the MCO
23    and the provider.
24        (C) The Department shall share at least monthly its
25    expedited provider list and the frequency with which it
26    pays providers on the expedited list.

 

 

SB2088- 11 -LRB103 28984 KTG 55370 b

1    (g-5) Recognizing that the rapid transformation of the
2Illinois Medicaid program may have unintended operational
3challenges for both payers and providers:
4        (1) in no instance shall a medically necessary covered
5    service rendered in good faith, based upon eligibility
6    information documented by the provider, be denied coverage
7    or diminished in payment amount if the eligibility or
8    coverage information available at the time the service was
9    rendered is later found to be inaccurate in the assignment
10    of coverage responsibility between MCOs or the
11    fee-for-service system, except for instances when an
12    individual is deemed to have not been eligible for
13    coverage under the Illinois Medicaid program; and
14        (2) the Department shall, by December 31, 2016, adopt
15    rules establishing policies that shall be included in the
16    Medicaid managed care policy and procedures manual
17    addressing payment resolutions in situations in which a
18    provider renders services based upon information obtained
19    after verifying a patient's eligibility and coverage plan
20    through either the Department's current enrollment system
21    or a system operated by the coverage plan identified by
22    the patient presenting for services:
23            (A) such medically necessary covered services
24        shall be considered rendered in good faith;
25            (B) such policies and procedures shall be
26        developed in consultation with industry

 

 

SB2088- 12 -LRB103 28984 KTG 55370 b

1        representatives of the Medicaid managed care health
2        plans and representatives of provider associations
3        representing the majority of providers within the
4        identified provider industry; and
5            (C) such rules shall be published for a review and
6        comment period of no less than 30 days on the
7        Department's website with final rules remaining
8        available on the Department's website.
9        The rules on payment resolutions shall include, but
10    not be limited to:
11            (A) the extension of the timely filing period;
12            (B) retroactive prior authorizations; and
13            (C) guaranteed minimum payment rate of no less
14        than the current, as of the date of service,
15        fee-for-service rate, plus all applicable add-ons,
16        when the resulting service relationship is out of
17        network.
18        The rules shall be applicable for both MCO coverage
19    and fee-for-service coverage.
20    If the fee-for-service system is ultimately determined to
21have been responsible for coverage on the date of service, the
22Department shall provide for an extended period for claims
23submission outside the standard timely filing requirements.
24    (g-6) MCO Performance Metrics Report.
25        (1) The Department shall publish, on at least a
26    quarterly basis, each MCO's operational performance,

 

 

SB2088- 13 -LRB103 28984 KTG 55370 b

1    including, but not limited to, the following categories of
2    metrics:
3            (A) claims payment, including timeliness and
4        accuracy;
5            (B) prior authorizations;
6            (C) grievance and appeals;
7            (D) utilization statistics;
8            (E) provider disputes;
9            (F) provider credentialing; and
10            (G) member and provider customer service.
11        (2) The Department shall ensure that the metrics
12    report is accessible to providers online by January 1,
13    2017.
14        (3) The metrics shall be developed in consultation
15    with industry representatives of the Medicaid managed care
16    health plans and representatives of associations
17    representing the majority of providers within the
18    identified industry.
19        (4) Metrics shall be defined and incorporated into the
20    applicable Managed Care Policy Manual issued by the
21    Department.
22    (g-7) MCO claims processing and performance analysis. In
23order to monitor MCO payments to hospital providers, pursuant
24to Public Act 100-580, the Department shall post an analysis
25of MCO claims processing and payment performance on its
26website every 3 6 months. Such analysis shall include a review

 

 

SB2088- 14 -LRB103 28984 KTG 55370 b

1and evaluation of all Medicaid claims that were paid, denied,
2rejected, or otherwise adjudicated by each MCO in the
3preceding 3 months and were submitted to an MCO by a provider
4that submitted at least 20 Medicaid claims to that MCO during
5the period. The review and evaluation shall state a
6representative sample of hospital claims that are rejected and
7denied for clean and unclean claims and the top 5 reasons for
8the rejection or denial of clean and unclean claims and the
9time required for claim adjudication and payment, including
10identifying: such actions and timeliness of claims
11adjudication
12        (1) the total number of claims, by MCO, in the review
13    and evaluation;
14        (2) the percentage of all such claims, by MCO, that
15    were clean claims;
16        (3) the percentage of all claims, by MCO, that the MCO
17    paid within 30 days of receiving the claim, and the
18    percentage of all claims the MCO paid within 90 days of
19    receiving the claim;
20        (4) the percentage of clean claims the MCO paid within
21    30 days of receiving the claim, and the percentage of
22    clean claims the MCO paid within 90 days of receiving the
23    claim;
24        (5) the aggregate dollar amounts of those claims
25    identified in paragraphs (3) and (4).
26    Individual providers that submitted claims that are

 

 

SB2088- 15 -LRB103 28984 KTG 55370 b

1included in any Department review and evaluation required by
2this subsection may request, and the Department shall provide
3to such provider within 14 days thereafter, the data used by
4the Department in its review and analysis that pertains to
5claims submitted by that provider. The Department shall post
6the contracted claims report required by HealthChoice Illinois
7on its website every 3 months.
8, which identifies the percentage of claims adjudicated within
930, 60, 90, and over 90 days, and the dollar amounts associated
10with those claims.
11    (g-8) Dispute resolution process. The Department shall
12maintain a provider complaint portal through which a provider
13can submit to the Department unresolved disputes with an MCO.
14An unresolved dispute means an MCO's decision that denies in
15whole or in part a claim for reimbursement to a provider for
16health care services rendered by the provider to an enrollee
17of the MCO with which the provider disagrees. Disputes shall
18not be submitted to the portal until the provider has availed
19itself of the MCO's internal dispute resolution process.
20Disputes that are submitted to the MCO internal dispute
21resolution process may be submitted to the Department of
22Healthcare and Family Services' complaint portal no sooner
23than 30 days after submitting to the MCO's internal process
24and not later than 30 days after the unsatisfactory resolution
25of the internal MCO process or 60 days after submitting the
26dispute to the MCO internal process. Multiple claim disputes

 

 

SB2088- 16 -LRB103 28984 KTG 55370 b

1involving the same MCO may be submitted in one complaint,
2regardless of whether the claims are for different enrollees,
3when the specific reason for non-payment of the claims
4involves a common question of fact or policy. Within 10
5business days of receipt of a complaint, the Department shall
6present such disputes to the appropriate MCO, which shall then
7have 30 days to issue its written proposal to resolve the
8dispute. The Department may grant one 30-day extension of this
9time frame to one of the parties to resolve the dispute. If the
10dispute remains unresolved at the end of this time frame or the
11provider is not satisfied with the MCO's written proposal to
12resolve the dispute, the provider may, within 30 days, request
13the Department to review the dispute and make a final
14determination. Within 30 days of the request for Department
15review of the dispute, both the provider and the MCO shall
16present all relevant information to the Department for
17resolution and make individuals with knowledge of the issues
18available to the Department for further inquiry if needed.
19Within 30 days of receiving the relevant information on the
20dispute, or the lapse of the period for submitting such
21information, the Department shall issue a written decision on
22the dispute based on contractual terms between the provider
23and the MCO, contractual terms between the MCO and the
24Department of Healthcare and Family Services and applicable
25Medicaid policy. The decision of the Department shall be
26final. By January 1, 2020, the Department shall establish by

 

 

SB2088- 17 -LRB103 28984 KTG 55370 b

1rule further details of this dispute resolution process.
2Disputes between MCOs and providers presented to the
3Department for resolution are not contested cases, as defined
4in Section 1-30 of the Illinois Administrative Procedure Act,
5conferring any right to an administrative hearing.
6    (g-9)(1) The Department shall publish annually on its
7website a report on the calculation of each managed care
8organization's medical loss ratio showing the following:
9        (A) Premium revenue, with appropriate adjustments.
10        (B) Benefit expense, setting forth the aggregate
11    amount spent for the following:
12            (i) Direct paid claims.
13            (ii) Subcapitation payments.
14            (iii) Other claim payments.
15            (iv) Direct reserves.
16            (v) Gross recoveries.
17            (vi) Expenses for activities that improve health
18        care quality as allowed by the Department.
19    (3) The report shall also include the total amounts of all
20Hospital Assessment Program-related payments made to the MCO,
21and whether such amounts exceed the actual increased amounts
22paid by the MCO to providers as a result of HAP-associated rate
23increases.
24    (2) The medical loss ratio shall be calculated consistent
25with federal law and regulation following a claims runout
26period determined by the Department.

 

 

SB2088- 18 -LRB103 28984 KTG 55370 b

1    (g-10)(1) "Liability effective date" means the date on
2which an MCO becomes responsible for payment for medically
3necessary and covered services rendered by a provider to one
4of its enrollees in accordance with the contract terms between
5the MCO and the provider. The liability effective date shall
6be the later of:
7        (A) The execution date of a network participation
8    contract agreement.
9        (B) The date the provider or its representative
10    submits to the MCO the complete and accurate standardized
11    roster form for the provider in the format approved by the
12    Department.
13        (C) The provider effective date contained within the
14    Department's provider enrollment subsystem within the
15    Illinois Medicaid Program Advanced Cloud Technology
16    (IMPACT) System.
17    (2) The standardized roster form may be submitted to the
18MCO at the same time that the provider submits an enrollment
19application to the Department through IMPACT.
20    (3) By October 1, 2019, the Department shall require all
21MCOs to update their provider directory with information for
22new practitioners of existing contracted providers within 30
23days of receipt of a complete and accurate standardized roster
24template in the format approved by the Department provided
25that the provider is effective in the Department's provider
26enrollment subsystem within the IMPACT system. Such provider

 

 

SB2088- 19 -LRB103 28984 KTG 55370 b

1directory shall be readily accessible for purposes of
2selecting an approved health care provider and comply with all
3other federal and State requirements.
4    (g-11) The Department shall work with relevant
5stakeholders on the development of operational guidelines to
6enhance and improve operational performance of Illinois'
7Medicaid managed care program, including, but not limited to,
8improving provider billing practices, reducing claim
9rejections and inappropriate payment denials, and
10standardizing processes, procedures, definitions, and response
11timelines, with the goal of reducing provider and MCO
12administrative burdens and conflict. The Department shall
13include a report on the progress of these program improvements
14and other topics in its Fiscal Year 2020 annual report to the
15General Assembly.
16    (g-12) Notwithstanding any other provision of law, if the
17Department or an MCO requires submission of a claim for
18payment in a non-electronic format, a provider shall always be
19afforded a period of no less than 90 business days, as a
20correction period, following any notification of rejection by
21either the Department or the MCO to correct errors or
22omissions in the original submission.
23    Under no circumstances, either by an MCO or under the
24State's fee-for-service system, shall a provider be denied
25payment for failure to comply with any timely submission
26requirements under this Code or under any existing contract,

 

 

SB2088- 20 -LRB103 28984 KTG 55370 b

1unless the non-electronic format claim submission occurs after
2the initial 180 days following the latest date of service on
3the claim, or after the 90 business days correction period
4following notification to the provider of rejection or denial
5of payment.
6    At the time of payment for a claim, an MCO shall report to
7the provider the payment components applicable to the payment,
8including the base rate, the Diagnosis-Related Group (DRG) or
9Enhanced Ambulatory Procedure Grouping (EAPG) group and
10weight, any add-ons or adjustors, and any interest.
11    (g-13) The Department shall audit on a quarterly basis a
12representative sample of claims that each MCO pays to a
13representative sample of hospitals to determine if the MCOs
14are accurately paying claims, including the base rate, the DRG
15or EAPG group and weight, any add-ons or adjustors, and any
16interest.
17        (1) If the Department finds that an MCO has improperly
18    denied or underpaid on a claim, the Department shall
19    promptly communicate the underpayment to the MCO and
20    provider, and take such steps as necessary to see that the
21    amount due is paid.
22        (2) The Department shall also investigate whether the
23    error affected other providers, and if so, notify affected
24    providers.
25        (3) The findings of the audits shall be included in
26    the quarterly MCO Performance Metrics Report under

 

 

SB2088- 21 -LRB103 28984 KTG 55370 b

1    subsection (g-6).
2    (h) The Department shall not expand mandatory MCO
3enrollment into new counties beyond those counties already
4designated by the Department as of June 1, 2014 for the
5individuals whose eligibility for medical assistance is not
6the seniors or people with disabilities population until the
7Department provides an opportunity for accountable care
8entities and MCOs to participate in such newly designated
9counties.
10    (i) The requirements of this Section apply to contracts
11with accountable care entities and MCOs entered into, amended,
12or renewed after June 16, 2014 (the effective date of Public
13Act 98-651).
14    (j) Health care information released to managed care
15organizations. A health care provider shall release to a
16Medicaid managed care organization, upon request, and subject
17to the Health Insurance Portability and Accountability Act of
181996 and any other law applicable to the release of health
19information, the health care information of the MCO's
20enrollee, if the enrollee has completed and signed a general
21release form that grants to the health care provider
22permission to release the recipient's health care information
23to the recipient's insurance carrier.
24    (k) The Department of Healthcare and Family Services,
25managed care organizations, a statewide organization
26representing hospitals, and a statewide organization

 

 

SB2088- 22 -LRB103 28984 KTG 55370 b

1representing safety-net hospitals shall explore ways to
2support billing departments in safety-net hospitals.
3    (l) The requirements of this Section added by Public Act
4102-4 shall apply to services provided on or after the first
5day of the month that begins 60 days after April 27, 2021 (the
6effective date of Public Act 102-4).
7    (m) MCOs operated as part of or by any unit of State or
8local government shall segregate any Medicaid funds received
9from the State or any State agency for payments to providers
10separately from the governmental entity's general operating
11and other funds and shall use such Medicaid funds only for the
12Medicaid purposes for which the funds were paid to it by the
13State or State agency.
14(Source: P.A. 101-209, eff. 8-5-19; 102-4, eff. 4-27-21;
15102-43, eff. 7-6-21; 102-144, eff. 1-1-22; 102-454, eff.
168-20-21; 102-813, eff. 5-13-22.)
 
17    (305 ILCS 5/5A-12.7)
18    (Section scheduled to be repealed on December 31, 2026)
19    Sec. 5A-12.7. Continuation of hospital access payments on
20and after July 1, 2020.
21    (a) To preserve and improve access to hospital services,
22for hospital services rendered on and after July 1, 2020, the
23Department shall, except for hospitals described in subsection
24(b) of Section 5A-3, make payments to hospitals or require
25capitated managed care organizations to make payments as set

 

 

SB2088- 23 -LRB103 28984 KTG 55370 b

1forth in this Section. Payments under this Section are not due
2and payable, however, until: (i) the methodologies described
3in this Section are approved by the federal government in an
4appropriate State Plan amendment or directed payment preprint;
5and (ii) the assessment imposed under this Article is
6determined to be a permissible tax under Title XIX of the
7Social Security Act. In determining the hospital access
8payments authorized under subsection (g) of this Section, if a
9hospital ceases to qualify for payments from the pool, the
10payments for all hospitals continuing to qualify for payments
11from such pool shall be uniformly adjusted to fully expend the
12aggregate net amount of the pool, with such adjustment being
13effective on the first day of the second month following the
14date the hospital ceases to receive payments from such pool.
15    (b) Amounts moved into claims-based rates and distributed
16in accordance with Section 14-12 shall remain in those
17claims-based rates.
18    (c) Graduate medical education.
19        (1) The calculation of graduate medical education
20    payments shall be based on the hospital's Medicare cost
21    report ending in Calendar Year 2018, as reported in the
22    Healthcare Cost Report Information System file, release
23    date September 30, 2019. An Illinois hospital reporting
24    intern and resident cost on its Medicare cost report shall
25    be eligible for graduate medical education payments.
26        (2) Each hospital's annualized Medicaid Intern

 

 

SB2088- 24 -LRB103 28984 KTG 55370 b

1    Resident Cost is calculated using annualized intern and
2    resident total costs obtained from Worksheet B Part I,
3    Columns 21 and 22 the sum of Lines 30-43, 50-76, 90-93,
4    96-98, and 105-112 multiplied by the percentage that the
5    hospital's Medicaid days (Worksheet S3 Part I, Column 7,
6    Lines 2, 3, 4, 14, 16-18, and 32) comprise of the
7    hospital's total days (Worksheet S3 Part I, Column 8,
8    Lines 14, 16-18, and 32).
9        (3) An annualized Medicaid indirect medical education
10    (IME) payment is calculated for each hospital using its
11    IME payments (Worksheet E Part A, Line 29, Column 1)
12    multiplied by the percentage that its Medicaid days
13    (Worksheet S3 Part I, Column 7, Lines 2, 3, 4, 14, 16-18,
14    and 32) comprise of its Medicare days (Worksheet S3 Part
15    I, Column 6, Lines 2, 3, 4, 14, and 16-18).
16        (4) For each hospital, its annualized Medicaid Intern
17    Resident Cost and its annualized Medicaid IME payment are
18    summed, and, except as capped at 120% of the average cost
19    per intern and resident for all qualifying hospitals as
20    calculated under this paragraph, is multiplied by the
21    applicable reimbursement factor as described in this
22    paragraph, to determine the hospital's final graduate
23    medical education payment. Each hospital's average cost
24    per intern and resident shall be calculated by summing its
25    total annualized Medicaid Intern Resident Cost plus its
26    annualized Medicaid IME payment and dividing that amount

 

 

SB2088- 25 -LRB103 28984 KTG 55370 b

1    by the hospital's total Full Time Equivalent Residents and
2    Interns. If the hospital's average per intern and resident
3    cost is greater than 120% of the same calculation for all
4    qualifying hospitals, the hospital's per intern and
5    resident cost shall be capped at 120% of the average cost
6    for all qualifying hospitals.
7            (A) For the period of July 1, 2020 through
8        December 31, 2022, the applicable reimbursement factor
9        shall be 22.6%.
10            (B) For the period of January 1, 2023 through
11        December 31, 2026, the applicable reimbursement factor
12        shall be 35% for all qualified safety-net hospitals,
13        as defined in Section 5-5e.1 of this Code, and all
14        hospitals with 100 or more Full Time Equivalent
15        Residents and Interns, as reported on the hospital's
16        Medicare cost report ending in Calendar Year 2018, and
17        for all other qualified hospitals the applicable
18        reimbursement factor shall be 30%.
19    (d) Fee-for-service supplemental payments. For the period
20of July 1, 2020 through December 31, 2022, each Illinois
21hospital shall receive an annual payment equal to the amounts
22below, to be paid in 12 equal installments on or before the
23seventh State business day of each month, except that no
24payment shall be due within 30 days after the later of the date
25of notification of federal approval of the payment
26methodologies required under this Section or any waiver

 

 

SB2088- 26 -LRB103 28984 KTG 55370 b

1required under 42 CFR 433.68, at which time the sum of amounts
2required under this Section prior to the date of notification
3is due and payable.
4        (1) For critical access hospitals, $385 per covered
5    inpatient day contained in paid fee-for-service claims and
6    $530 per paid fee-for-service outpatient claim for dates
7    of service in Calendar Year 2019 in the Department's
8    Enterprise Data Warehouse as of May 11, 2020.
9        (2) For safety-net hospitals, $960 per covered
10    inpatient day contained in paid fee-for-service claims and
11    $625 per paid fee-for-service outpatient claim for dates
12    of service in Calendar Year 2019 in the Department's
13    Enterprise Data Warehouse as of May 11, 2020.
14        (3) For long term acute care hospitals, $295 per
15    covered inpatient day contained in paid fee-for-service
16    claims for dates of service in Calendar Year 2019 in the
17    Department's Enterprise Data Warehouse as of May 11, 2020.
18        (4) For freestanding psychiatric hospitals, $125 per
19    covered inpatient day contained in paid fee-for-service
20    claims and $130 per paid fee-for-service outpatient claim
21    for dates of service in Calendar Year 2019 in the
22    Department's Enterprise Data Warehouse as of May 11, 2020.
23        (5) For freestanding rehabilitation hospitals, $355
24    per covered inpatient day contained in paid
25    fee-for-service claims for dates of service in Calendar
26    Year 2019 in the Department's Enterprise Data Warehouse as

 

 

SB2088- 27 -LRB103 28984 KTG 55370 b

1    of May 11, 2020.
2        (6) For all general acute care hospitals and high
3    Medicaid hospitals as defined in subsection (f), $350 per
4    covered inpatient day for dates of service in Calendar
5    Year 2019 contained in paid fee-for-service claims and
6    $620 per paid fee-for-service outpatient claim in the
7    Department's Enterprise Data Warehouse as of May 11, 2020.
8        (7) Alzheimer's treatment access payment. Each
9    Illinois academic medical center or teaching hospital, as
10    defined in Section 5-5e.2 of this Code, that is identified
11    as the primary hospital affiliate of one of the Regional
12    Alzheimer's Disease Assistance Centers, as designated by
13    the Alzheimer's Disease Assistance Act and identified in
14    the Department of Public Health's Alzheimer's Disease
15    State Plan dated December 2016, shall be paid an
16    Alzheimer's treatment access payment equal to the product
17    of the qualifying hospital's State Fiscal Year 2018 total
18    inpatient fee-for-service days multiplied by the
19    applicable Alzheimer's treatment rate of $226.30 for
20    hospitals located in Cook County and $116.21 for hospitals
21    located outside Cook County.
22    (d-2) Fee-for-service supplemental payments. Beginning
23January 1, 2023, each Illinois hospital shall receive an
24annual payment equal to the amounts listed below, to be paid in
2512 equal installments on or before the seventh State business
26day of each month, except that no payment shall be due within

 

 

SB2088- 28 -LRB103 28984 KTG 55370 b

130 days after the later of the date of notification of federal
2approval of the payment methodologies required under this
3Section or any waiver required under 42 CFR 433.68, at which
4time the sum of amounts required under this Section prior to
5the date of notification is due and payable. The Department
6may adjust the rates in paragraphs (1) through (7) to comply
7with the federal upper payment limits, with such adjustments
8being determined so that the total estimated spending by
9hospital class, under such adjusted rates, remains
10substantially similar to the total estimated spending under
11the original rates set forth in this subsection.
12        (1) For critical access hospitals, as defined in
13    subsection (f), $750 per covered inpatient day contained
14    in paid fee-for-service claims and $750 per paid
15    fee-for-service outpatient claim for dates of service in
16    Calendar Year 2019 in the Department's Enterprise Data
17    Warehouse as of August 6, 2021.
18        (2) For safety-net hospitals, as described in
19    subsection (f), $1,350 per inpatient day contained in paid
20    fee-for-service claims and $1,350 per paid fee-for-service
21    outpatient claim for dates of service in Calendar Year
22    2019 in the Department's Enterprise Data Warehouse as of
23    August 6, 2021.
24        (3) For long term acute care hospitals, $550 per
25    covered inpatient day contained in paid fee-for-service
26    claims for dates of service in Calendar Year 2019 in the

 

 

SB2088- 29 -LRB103 28984 KTG 55370 b

1    Department's Enterprise Data Warehouse as of August 6,
2    2021.
3        (4) For freestanding psychiatric hospitals, $200 per
4    covered inpatient day contained in paid fee-for-service
5    claims and $200 per paid fee-for-service outpatient claim
6    for dates of service in Calendar Year 2019 in the
7    Department's Enterprise Data Warehouse as of August 6,
8    2021.
9        (5) For freestanding rehabilitation hospitals, $550
10    per covered inpatient day contained in paid
11    fee-for-service claims and $125 per paid fee-for-service
12    outpatient claim for dates of service in Calendar Year
13    2019 in the Department's Enterprise Data Warehouse as of
14    August 6, 2021.
15        (6) For all general acute care hospitals and high
16    Medicaid hospitals as defined in subsection (f), $500 per
17    covered inpatient day for dates of service in Calendar
18    Year 2019 contained in paid fee-for-service claims and
19    $500 per paid fee-for-service outpatient claim in the
20    Department's Enterprise Data Warehouse as of August 6,
21    2021.
22        (7) For public hospitals, as defined in subsection
23    (f), $275 per covered inpatient day contained in paid
24    fee-for-service claims and $275 per paid fee-for-service
25    outpatient claim for dates of service in Calendar Year
26    2019 in the Department's Enterprise Data Warehouse as of

 

 

SB2088- 30 -LRB103 28984 KTG 55370 b

1    August 6, 2021.
2        (8) Alzheimer's treatment access payment. Each
3    Illinois academic medical center or teaching hospital, as
4    defined in Section 5-5e.2 of this Code, that is identified
5    as the primary hospital affiliate of one of the Regional
6    Alzheimer's Disease Assistance Centers, as designated by
7    the Alzheimer's Disease Assistance Act and identified in
8    the Department of Public Health's Alzheimer's Disease
9    State Plan dated December 2016, shall be paid an
10    Alzheimer's treatment access payment equal to the product
11    of the qualifying hospital's Calendar Year 2019 total
12    inpatient fee-for-service days, in the Department's
13    Enterprise Data Warehouse as of August 6, 2021, multiplied
14    by the applicable Alzheimer's treatment rate of $244.37
15    for hospitals located in Cook County and $312.03 for
16    hospitals located outside Cook County.
17    (e) The Department shall require managed care
18organizations (MCOs) to make directed payments and
19pass-through payments according to this Section. Each calendar
20year, the Department shall require MCOs to pay the maximum
21amount out of these funds as allowed as pass-through payments
22under federal regulations. The Department shall require MCOs
23to make such pass-through payments as specified in this
24Section. The Department shall require the MCOs to pay the
25remaining amounts as directed Payments as specified in this
26Section. The Department shall issue payments to the

 

 

SB2088- 31 -LRB103 28984 KTG 55370 b

1Comptroller by the seventh business day of each month for all
2MCOs that are sufficient for MCOs to make the directed
3payments and pass-through payments according to this Section.
4The Department shall require the MCOs to make pass-through
5payments and directed payments using electronic funds
6transfers (EFT), if the hospital provides the information
7necessary to process such EFTs, in accordance with directions
8provided monthly by the Department, within 7 business days of
9the date the funds are paid to the MCOs, as indicated by the
10"Paid Date" on the website of the Office of the Comptroller if
11the funds are paid by EFT and the MCOs have received directed
12payment instructions. If funds are not paid through the
13Comptroller by EFT, payment must be made within 7 business
14days of the date actually received by the MCO. The MCO will be
15considered to have paid the pass-through payments when the
16payment remittance number is generated or the date the MCO
17sends the check to the hospital, if EFT information is not
18supplied. If an MCO is late in paying a pass-through payment or
19directed payment as required under this Section (including any
20extensions granted by the Department), it shall pay a penalty,
21unless waived by the Department for reasonable cause, to the
22Department equal to 5% of the amount of the pass-through
23payment or directed payment not paid on or before the due date
24plus 5% of the portion thereof remaining unpaid on the last day
25of each 30-day period thereafter. Payments to MCOs that would
26be paid consistent with actuarial certification and enrollment

 

 

SB2088- 32 -LRB103 28984 KTG 55370 b

1in the absence of the increased capitation payments under this
2Section shall not be reduced as a consequence of payments made
3under this subsection. The Department shall publish and
4maintain on its website for a period of no less than 8 calendar
5quarters, the quarterly calculation of directed payments and
6pass-through payments owed to each hospital from each MCO. All
7calculations and reports shall be posted no later than the
8first day of the quarter for which the payments are to be
9issued.
10    (f)(1) For purposes of allocating the funds included in
11capitation payments to MCOs, Illinois hospitals shall be
12divided into the following classes as defined in
13administrative rules:
14        (A) Beginning July 1, 2020 through December 31, 2022,
15    critical access hospitals. Beginning January 1, 2023,
16    "critical access hospital" means a hospital designated by
17    the Department of Public Health as a critical access
18    hospital, excluding any hospital meeting the definition of
19    a public hospital in subparagraph (F).
20        (B) Safety-net hospitals, except that stand-alone
21    children's hospitals that are not specialty children's
22    hospitals will not be included. For the calendar year
23    beginning January 1, 2023, and each calendar year
24    thereafter, assignment to the safety-net class shall be
25    based on the annual safety-net rate year beginning 15
26    months before the beginning of the first Payout Quarter of

 

 

SB2088- 33 -LRB103 28984 KTG 55370 b

1    the calendar year.
2        (C) Long term acute care hospitals.
3        (D) Freestanding psychiatric hospitals.
4        (E) Freestanding rehabilitation hospitals.
5        (F) Beginning January 1, 2023, "public hospital" means
6    a hospital that is owned or operated by an Illinois
7    Government body or municipality, excluding a hospital
8    provider that is a State agency, a State university, or a
9    county with a population of 3,000,000 or more.
10        (G) High Medicaid hospitals.
11            (i) As used in this Section, "high Medicaid
12        hospital" means a general acute care hospital that:
13                (I) For the payout periods July 1, 2020
14            through December 31, 2022, is not a safety-net
15            hospital or critical access hospital and that has
16            a Medicaid Inpatient Utilization Rate above 30% or
17            a hospital that had over 35,000 inpatient Medicaid
18            days during the applicable period. For the period
19            July 1, 2020 through December 31, 2020, the
20            applicable period for the Medicaid Inpatient
21            Utilization Rate (MIUR) is the rate year 2020 MIUR
22            and for the number of inpatient days it is State
23            fiscal year 2018. Beginning in calendar year 2021,
24            the Department shall use the most recently
25            determined MIUR, as defined in subsection (h) of
26            Section 5-5.02, and for the inpatient day

 

 

SB2088- 34 -LRB103 28984 KTG 55370 b

1            threshold, the State fiscal year ending 18 months
2            prior to the beginning of the calendar year. For
3            purposes of calculating MIUR under this Section,
4            children's hospitals and affiliated general acute
5            care hospitals shall be considered a single
6            hospital.
7                (II) For the calendar year beginning January
8            1, 2023, and each calendar year thereafter, is not
9            a public hospital, safety-net hospital, or
10            critical access hospital and that qualifies as a
11            regional high volume hospital or is a hospital
12            that has a Medicaid Inpatient Utilization Rate
13            (MIUR) above 30%. As used in this item, "regional
14            high volume hospital" means a hospital which ranks
15            in the top 2 quartiles based on total hospital
16            services volume, of all eligible general acute
17            care hospitals, when ranked in descending order
18            based on total hospital services volume, within
19            the same Medicaid managed care region, as
20            designated by the Department, as of January 1,
21            2022. As used in this item, "total hospital
22            services volume" means the total of all Medical
23            Assistance hospital inpatient admissions plus all
24            Medical Assistance hospital outpatient visits. For
25            purposes of determining regional high volume
26            hospital inpatient admissions and outpatient

 

 

SB2088- 35 -LRB103 28984 KTG 55370 b

1            visits, the Department shall use dates of service
2            provided during State Fiscal Year 2020 for the
3            Payout Quarter beginning January 1, 2023. The
4            Department shall use dates of service from the
5            State fiscal year ending 18 month before the
6            beginning of the first Payout Quarter of the
7            subsequent annual determination period.
8            (ii) For the calendar year beginning January 1,
9        2023, the Department shall use the Rate Year 2022
10        Medicaid inpatient utilization rate (MIUR), as defined
11        in subsection (h) of Section 5-5.02. For each
12        subsequent annual determination, the Department shall
13        use the MIUR applicable to the rate year ending
14        September 30 of the year preceding the beginning of
15        the calendar year.
16        (H) General acute care hospitals. As used under this
17    Section, "general acute care hospitals" means all other
18    Illinois hospitals not identified in subparagraphs (A)
19    through (G).
20    (2) Hospitals' qualification for each class shall be
21assessed prior to the beginning of each calendar year and the
22new class designation shall be effective January 1 of the next
23year. The Department shall publish by rule the process for
24establishing class determination.
25    (g) Fixed pool directed payments. Beginning July 1, 2020,
26the Department shall issue payments to MCOs which shall be

 

 

SB2088- 36 -LRB103 28984 KTG 55370 b

1used to issue directed payments to qualified Illinois
2safety-net hospitals and critical access hospitals on a
3monthly basis in accordance with this subsection. Prior to the
4beginning of each Payout Quarter beginning July 1, 2020, the
5Department shall use encounter claims data from the
6Determination Quarter, accepted by the Department's Medicaid
7Management Information System for inpatient and outpatient
8services rendered by safety-net hospitals and critical access
9hospitals to determine a quarterly uniform per unit add-on for
10each hospital class.
11        (1) Inpatient per unit add-on. A quarterly uniform per
12    diem add-on shall be derived by dividing the quarterly
13    Inpatient Directed Payments Pool amount allocated to the
14    applicable hospital class by the total inpatient days
15    contained on all encounter claims received during the
16    Determination Quarter, for all hospitals in the class.
17            (A) Each hospital in the class shall have a
18        quarterly inpatient directed payment calculated that
19        is equal to the product of the number of inpatient days
20        attributable to the hospital used in the calculation
21        of the quarterly uniform class per diem add-on,
22        multiplied by the calculated applicable quarterly
23        uniform class per diem add-on of the hospital class.
24            (B) Each hospital shall be paid 1/3 of its
25        quarterly inpatient directed payment in each of the 3
26        months of the Payout Quarter, in accordance with

 

 

SB2088- 37 -LRB103 28984 KTG 55370 b

1        directions provided to each MCO by the Department.
2        (2) Outpatient per unit add-on. A quarterly uniform
3    per claim add-on shall be derived by dividing the
4    quarterly Outpatient Directed Payments Pool amount
5    allocated to the applicable hospital class by the total
6    outpatient encounter claims received during the
7    Determination Quarter, for all hospitals in the class.
8            (A) Each hospital in the class shall have a
9        quarterly outpatient directed payment calculated that
10        is equal to the product of the number of outpatient
11        encounter claims attributable to the hospital used in
12        the calculation of the quarterly uniform class per
13        claim add-on, multiplied by the calculated applicable
14        quarterly uniform class per claim add-on of the
15        hospital class.
16            (B) Each hospital shall be paid 1/3 of its
17        quarterly outpatient directed payment in each of the 3
18        months of the Payout Quarter, in accordance with
19        directions provided to each MCO by the Department.
20        (3) Each MCO shall pay each hospital the Monthly
21    Directed Payment as identified by the Department on its
22    quarterly determination report.
23        (4) Definitions. As used in this subsection:
24            (A) "Payout Quarter" means each 3 month calendar
25        quarter, beginning July 1, 2020.
26            (B) "Determination Quarter" means each 3 month

 

 

SB2088- 38 -LRB103 28984 KTG 55370 b

1        calendar quarter, which ends 3 months prior to the
2        first day of each Payout Quarter.
3        (5) For the period July 1, 2020 through December 2020,
4    the following amounts shall be allocated to the following
5    hospital class directed payment pools for the quarterly
6    development of a uniform per unit add-on:
7            (A) $2,894,500 for hospital inpatient services for
8        critical access hospitals.
9            (B) $4,294,374 for hospital outpatient services
10        for critical access hospitals.
11            (C) $29,109,330 for hospital inpatient services
12        for safety-net hospitals.
13            (D) $35,041,218 for hospital outpatient services
14        for safety-net hospitals.
15        (6) For the period January 1, 2023 through December
16    31, 2023, the Department shall establish the amounts that
17    shall be allocated to the hospital class directed payment
18    fixed pools identified in this paragraph for the quarterly
19    development of a uniform per unit add-on. The Department
20    shall establish such amounts so that the total amount of
21    payments to each hospital under this Section in calendar
22    year 2023 is projected to be substantially similar to the
23    total amount of such payments received by the hospital
24    under this Section in calendar year 2021, adjusted for
25    increased funding provided for fixed pool directed
26    payments under subsection (g) in calendar year 2022,

 

 

SB2088- 39 -LRB103 28984 KTG 55370 b

1    assuming that the volume and acuity of claims are held
2    constant. The Department shall publish the directed
3    payment fixed pool amounts to be established under this
4    paragraph on its website by November 15, 2022.
5            (A) Hospital inpatient services for critical
6        access hospitals.
7            (B) Hospital outpatient services for critical
8        access hospitals.
9            (C) Hospital inpatient services for public
10        hospitals.
11            (D) Hospital outpatient services for public
12        hospitals.
13            (E) Hospital inpatient services for safety-net
14        hospitals.
15            (F) Hospital outpatient services for safety-net
16        hospitals.
17        (7) Semi-annual rate maintenance review. The
18    Department shall ensure that hospitals assigned to the
19    fixed pools in paragraph (6) are paid no less than 95% of
20    the annual initial rate for each 6-month period of each
21    annual payout period. For each calendar year, the
22    Department shall calculate the annual initial rate per day
23    and per visit for each fixed pool hospital class listed in
24    paragraph (6), by dividing the total of all applicable
25    inpatient or outpatient directed payments issued in the
26    preceding calendar year to the hospitals in each fixed

 

 

SB2088- 40 -LRB103 28984 KTG 55370 b

1    pool class for the calendar year, plus any increase
2    resulting from the annual adjustments described in
3    subsection (i), by the actual applicable total service
4    units for the preceding calendar year which were the basis
5    of the total applicable inpatient or outpatient directed
6    payments issued to the hospitals in each fixed pool class
7    in the calendar year, except that for calendar year 2023,
8    the service units from calendar year 2021 shall be used.
9            (A) The Department shall calculate the effective
10        rate, per day and per visit, for the payout periods of
11        January to June and July to December of each year, for
12        each fixed pool listed in paragraph (6), by dividing
13        50% of the annual pool by the total applicable
14        reported service units for the 2 applicable
15        determination quarters.
16            (B) If the effective rate calculated in
17        subparagraph (A) is less than 95% of the annual
18        initial rate assigned to the class for each pool under
19        paragraph (6), the Department shall adjust the payment
20        for each hospital to a level equal to no less than 95%
21        of the annual initial rate, by issuing a retroactive
22        adjustment payment for the 6-month period under review
23        as identified in subparagraph (A).
24    (h) Fixed rate directed payments. Effective July 1, 2020,
25the Department shall issue payments to MCOs which shall be
26used to issue directed payments to Illinois hospitals not

 

 

SB2088- 41 -LRB103 28984 KTG 55370 b

1identified in paragraph (g) on a monthly basis. Prior to the
2beginning of each Payout Quarter beginning July 1, 2020, the
3Department shall use encounter claims data from the
4Determination Quarter, accepted by the Department's Medicaid
5Management Information System for inpatient and outpatient
6services rendered by hospitals in each hospital class
7identified in paragraph (f) and not identified in paragraph
8(g). For the period July 1, 2020 through December 2020, the
9Department shall direct MCOs to make payments as follows:
10        (1) For general acute care hospitals an amount equal
11    to $1,750 multiplied by the hospital's category of service
12    20 case mix index for the determination quarter multiplied
13    by the hospital's total number of inpatient admissions for
14    category of service 20 for the determination quarter.
15        (2) For general acute care hospitals an amount equal
16    to $160 multiplied by the hospital's category of service
17    21 case mix index for the determination quarter multiplied
18    by the hospital's total number of inpatient admissions for
19    category of service 21 for the determination quarter.
20        (3) For general acute care hospitals an amount equal
21    to $80 multiplied by the hospital's category of service 22
22    case mix index for the determination quarter multiplied by
23    the hospital's total number of inpatient admissions for
24    category of service 22 for the determination quarter.
25        (4) For general acute care hospitals an amount equal
26    to $375 multiplied by the hospital's category of service

 

 

SB2088- 42 -LRB103 28984 KTG 55370 b

1    24 case mix index for the determination quarter multiplied
2    by the hospital's total number of category of service 24
3    paid EAPG (EAPGs) for the determination quarter.
4        (5) For general acute care hospitals an amount equal
5    to $240 multiplied by the hospital's category of service
6    27 and 28 case mix index for the determination quarter
7    multiplied by the hospital's total number of category of
8    service 27 and 28 paid EAPGs for the determination
9    quarter.
10        (6) For general acute care hospitals an amount equal
11    to $290 multiplied by the hospital's category of service
12    29 case mix index for the determination quarter multiplied
13    by the hospital's total number of category of service 29
14    paid EAPGs for the determination quarter.
15        (7) For high Medicaid hospitals an amount equal to
16    $1,800 multiplied by the hospital's category of service 20
17    case mix index for the determination quarter multiplied by
18    the hospital's total number of inpatient admissions for
19    category of service 20 for the determination quarter.
20        (8) For high Medicaid hospitals an amount equal to
21    $160 multiplied by the hospital's category of service 21
22    case mix index for the determination quarter multiplied by
23    the hospital's total number of inpatient admissions for
24    category of service 21 for the determination quarter.
25        (9) For high Medicaid hospitals an amount equal to $80
26    multiplied by the hospital's category of service 22 case

 

 

SB2088- 43 -LRB103 28984 KTG 55370 b

1    mix index for the determination quarter multiplied by the
2    hospital's total number of inpatient admissions for
3    category of service 22 for the determination quarter.
4        (10) For high Medicaid hospitals an amount equal to
5    $400 multiplied by the hospital's category of service 24
6    case mix index for the determination quarter multiplied by
7    the hospital's total number of category of service 24 paid
8    EAPG outpatient claims for the determination quarter.
9        (11) For high Medicaid hospitals an amount equal to
10    $240 multiplied by the hospital's category of service 27
11    and 28 case mix index for the determination quarter
12    multiplied by the hospital's total number of category of
13    service 27 and 28 paid EAPGs for the determination
14    quarter.
15        (12) For high Medicaid hospitals an amount equal to
16    $290 multiplied by the hospital's category of service 29
17    case mix index for the determination quarter multiplied by
18    the hospital's total number of category of service 29 paid
19    EAPGs for the determination quarter.
20        (13) For long term acute care hospitals the amount of
21    $495 multiplied by the hospital's total number of
22    inpatient days for the determination quarter.
23        (14) For psychiatric hospitals the amount of $210
24    multiplied by the hospital's total number of inpatient
25    days for category of service 21 for the determination
26    quarter.

 

 

SB2088- 44 -LRB103 28984 KTG 55370 b

1        (15) For psychiatric hospitals the amount of $250
2    multiplied by the hospital's total number of outpatient
3    claims for category of service 27 and 28 for the
4    determination quarter.
5        (16) For rehabilitation hospitals the amount of $410
6    multiplied by the hospital's total number of inpatient
7    days for category of service 22 for the determination
8    quarter.
9        (17) For rehabilitation hospitals the amount of $100
10    multiplied by the hospital's total number of outpatient
11    claims for category of service 29 for the determination
12    quarter.
13        (18) Effective for the Payout Quarter beginning
14    January 1, 2023, for the directed payments to hospitals
15    required under this subsection, the Department shall
16    establish the amounts that shall be used to calculate such
17    directed payments using the methodologies specified in
18    this paragraph. The Department shall use a single, uniform
19    rate, adjusted for acuity as specified in paragraphs (1)
20    through (12), for all categories of inpatient services
21    provided by each class of hospitals and a single uniform
22    rate, adjusted for acuity as specified in paragraphs (1)
23    through (12), for all categories of outpatient services
24    provided by each class of hospitals. The Department shall
25    establish such amounts so that the total amount of
26    payments to each hospital under this Section in calendar

 

 

SB2088- 45 -LRB103 28984 KTG 55370 b

1    year 2023 is projected to be substantially similar to the
2    total amount of such payments received by the hospital
3    under this Section in calendar year 2021, adjusted for
4    increased funding provided for fixed pool directed
5    payments under subsection (g) in calendar year 2022,
6    assuming that the volume and acuity of claims are held
7    constant. The Department shall publish the directed
8    payment amounts to be established under this subsection on
9    its website by November 15, 2022.
10        (19) Each hospital shall be paid 1/3 of their
11    quarterly inpatient and outpatient directed payment in
12    each of the 3 months of the Payout Quarter, in accordance
13    with directions provided to each MCO by the Department.
14        20 Each MCO shall pay each hospital the Monthly
15    Directed Payment amount as identified by the Department on
16    its quarterly determination report.
17    Notwithstanding any other provision of this subsection, if
18the Department determines that the actual total hospital
19utilization data that is used to calculate the fixed rate
20directed payments is substantially different than anticipated
21when the rates in this subsection were initially determined
22for unforeseeable circumstances (such as the COVID-19 pandemic
23or some other public health emergency), the Department may
24adjust the rates specified in this subsection so that the
25total directed payments approximate the total spending amount
26anticipated when the rates were initially established.

 

 

SB2088- 46 -LRB103 28984 KTG 55370 b

1    Definitions. As used in this subsection:
2            (A) "Payout Quarter" means each calendar quarter,
3        beginning July 1, 2020.
4            (B) "Determination Quarter" means each calendar
5        quarter which ends 3 months prior to the first day of
6        each Payout Quarter.
7            (C) "Case mix index" means a hospital specific
8        calculation. For inpatient claims the case mix index
9        is calculated each quarter by summing the relative
10        weight of all inpatient Diagnosis-Related Group (DRG)
11        claims for a category of service in the applicable
12        Determination Quarter and dividing the sum by the
13        number of sum total of all inpatient DRG admissions
14        for the category of service for the associated claims.
15        The case mix index for outpatient claims is calculated
16        each quarter by summing the relative weight of all
17        paid EAPGs in the applicable Determination Quarter and
18        dividing the sum by the sum total of paid EAPGs for the
19        associated claims.
20    (i) Beginning January 1, 2021, the rates for directed
21payments shall be recalculated in order to spend the
22additional funds for directed payments that result from
23reduction in the amount of pass-through payments allowed under
24federal regulations. The additional funds for directed
25payments shall be allocated proportionally to each class of
26hospitals based on that class' proportion of services.

 

 

SB2088- 47 -LRB103 28984 KTG 55370 b

1        (1) Beginning January 1, 2024, the fixed pool directed
2    payment amounts and the associated annual initial rates
3    referenced in paragraph (6) of subsection (f) for each
4    hospital class shall be uniformly increased by a ratio of
5    not less than, the ratio of the total pass-through
6    reduction amount pursuant to paragraph (4) of subsection
7    (j), for the hospitals comprising the hospital fixed pool
8    directed payment class for the next calendar year, to the
9    total inpatient and outpatient directed payments for the
10    hospitals comprising the hospital fixed pool directed
11    payment class paid during the preceding calendar year.
12        (2) Beginning January 1, 2024, the fixed rates for the
13    directed payments referenced in paragraph (18) of
14    subsection (h) for each hospital class shall be uniformly
15    increased by a ratio of not less than, the ratio of the
16    total pass-through reduction amount pursuant to paragraph
17    (4) of subsection (j), for the hospitals comprising the
18    hospital directed payment class for the next calendar
19    year, to the total inpatient and outpatient directed
20    payments for the hospitals comprising the hospital fixed
21    rate directed payment class paid during the preceding
22    calendar year.
23    (j) Pass-through payments.
24        (1) For the period July 1, 2020 through December 31,
25    2020, the Department shall assign quarterly pass-through
26    payments to each class of hospitals equal to one-fourth of

 

 

SB2088- 48 -LRB103 28984 KTG 55370 b

1    the following annual allocations:
2            (A) $390,487,095 to safety-net hospitals.
3            (B) $62,553,886 to critical access hospitals.
4            (C) $345,021,438 to high Medicaid hospitals.
5            (D) $551,429,071 to general acute care hospitals.
6            (E) $27,283,870 to long term acute care hospitals.
7            (F) $40,825,444 to freestanding psychiatric
8        hospitals.
9            (G) $9,652,108 to freestanding rehabilitation
10        hospitals.
11        (2) For the period of July 1, 2020 through December
12    31, 2020, the pass-through payments shall at a minimum
13    ensure hospitals receive a total amount of monthly
14    payments under this Section as received in calendar year
15    2019 in accordance with this Article and paragraph (1) of
16    subsection (d-5) of Section 14-12, exclusive of amounts
17    received through payments referenced in subsection (b).
18        (3) For the calendar year beginning January 1, 2023,
19    the Department shall establish the annual pass-through
20    allocation to each class of hospitals and the pass-through
21    payments to each hospital so that the total amount of
22    payments to each hospital under this Section in calendar
23    year 2023 is projected to be substantially similar to the
24    total amount of such payments received by the hospital
25    under this Section in calendar year 2021, adjusted for
26    increased funding provided for fixed pool directed

 

 

SB2088- 49 -LRB103 28984 KTG 55370 b

1    payments under subsection (g) in calendar year 2022,
2    assuming that the volume and acuity of claims are held
3    constant. The Department shall publish the pass-through
4    allocation to each class and the pass-through payments to
5    each hospital to be established under this subsection on
6    its website by November 15, 2022.
7        (4) For the calendar years beginning January 1, 2021,
8    January 1, 2022, and January 1, 2024, and each calendar
9    year thereafter, each hospital's pass-through payment
10    amount shall be reduced proportionally to the reduction of
11    all pass-through payments required by federal regulations.
12    (k) At least 30 days prior to each calendar year, the
13Department shall notify each hospital of changes to the
14payment methodologies in this Section, including, but not
15limited to, changes in the fixed rate directed payment rates,
16the aggregate pass-through payment amount for all hospitals,
17and the hospital's pass-through payment amount for the
18upcoming calendar year.
19    (l) Notwithstanding any other provisions of this Section,
20the Department may adopt rules to change the methodology for
21directed and pass-through payments as set forth in this
22Section, but only to the extent necessary to obtain federal
23approval of a necessary State Plan amendment or Directed
24Payment Preprint or to otherwise conform to federal law or
25federal regulation.
26    (m) As used in this subsection, "managed care

 

 

SB2088- 50 -LRB103 28984 KTG 55370 b

1organization" or "MCO" means an entity which contracts with
2the Department to provide services where payment for medical
3services is made on a capitated basis, excluding contracted
4entities for dual eligible or Department of Children and
5Family Services youth populations.
6    (n) In order to address the escalating infant mortality
7rates among minority communities in Illinois, the State shall,
8subject to appropriation, create a pool of funding of at least
9$50,000,000 annually to be disbursed among safety-net
10hospitals that maintain perinatal designation from the
11Department of Public Health. The funding shall be used to
12preserve or enhance OB/GYN services or other specialty
13services at the receiving hospital, with the distribution of
14funding to be established by rule and with consideration to
15perinatal hospitals with safe birthing levels and quality
16metrics for healthy mothers and babies.
17    The Department shall calculate, at least quarterly, all
18Hospital Assessment Program-related funds paid to each
19hospital, whether paid by the Department or an MCO, including
20the amounts integrated into rate increases and distributed in
21accordance with Section 14-12 as provided under subsection (b)
22of Section 5A-12.7, and shall provide a report to each
23hospital stating the total payments made in the preceding
24quarter and including the data and mathematical formulas
25supporting its calculation.
26    (o) In order to address the growing challenges of

 

 

SB2088- 51 -LRB103 28984 KTG 55370 b

1providing stable access to healthcare in rural Illinois,
2including perinatal services, behavioral healthcare including
3substance use disorder services (SUDs) and other specialty
4services, and to expand access to telehealth services among
5rural communities in Illinois, the Department of Healthcare
6and Family Services, subject to appropriation, shall
7administer a program to provide at least $10,000,000 in
8financial support annually to critical access hospitals for
9delivery of perinatal and OB/GYN services, behavioral
10healthcare including SUDS, other specialty services and
11telehealth services. The funding shall be used to preserve or
12enhance perinatal and OB/GYN services, behavioral healthcare
13including SUDS, other specialty services, as well as the
14explanation of telehealth services by the receiving hospital,
15with the distribution of funding to be established by rule.
16    (p) For calendar year 2023, the final amounts, rates, and
17payments under subsections (c), (d-2), (g), (h), and (j) shall
18be established by the Department, so that the sum of the total
19estimated annual payments under subsections (c), (d-2), (g),
20(h), and (j) for each hospital class for calendar year 2023, is
21no less than:
22        (1) $858,260,000 to safety-net hospitals.
23        (2) $86,200,000 to critical access hospitals.
24        (3) $1,765,000,000 to high Medicaid hospitals.
25        (4) $673,860,000 to general acute care hospitals.
26        (5) $48,330,000 to long term acute care hospitals.

 

 

SB2088- 52 -LRB103 28984 KTG 55370 b

1        (6) $89,110,000 to freestanding psychiatric hospitals.
2        (7) $24,300,000 to freestanding rehabilitation
3    hospitals.
4        (8) $32,570,000 to public hospitals.
5    (q) Hospital Pandemic Recovery Stabilization Payments. The
6Department shall disburse a pool of $460,000,000 in stability
7payments to hospitals prior to April 1, 2023. The allocation
8of the pool shall be based on the hospital directed payment
9classes and directed payments issued, during Calendar Year
102022 with added consideration to safety net hospitals, as
11defined in subdivision (f)(1)(B) of this Section, and critical
12access hospitals.
13(Source: P.A. 101-650, eff. 7-7-20; 102-4, eff. 4-27-21;
14102-16, eff. 6-17-21; 102-886, eff. 5-17-22; 102-1115, eff.
151-9-23.)